Policy Manual Care Completed .pdf

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1|P ag e

Mayflower Care Home

Reviewed 30.03.2017

Quality Care Manual
Part 2

CARE

2|P ag e

Mayflower Care Home

Reviewed 30.03.2017

PROCEDURE

PAGE

Care-PR-01

Person Centered Care

6

Care-PR-02

Equal Opportunities for Residents

8

Care-PR-03

Privacy and Dignity

10

Care-PR-04

Strategic Participation in the Care Home

12

Care-PR-05

Concerns and Complaints

17

Care-PR-10

Pre Admission Enquiries

20

Care-PR-11

Pre-admission Assessment of a Potential Resident

21

Care-PR-12

Admission of a Resident

23

Care-PR-13

Care Files

28

Care-PR-14

Recording Professional Information

33

Care-PR-15

Access to Records

34

Care-PR-16
Care-PR-17

Care File Audit
Care Reviews

35
38

Care-PR-18

Key Worker Role

39

Care-PR-19
Care-PR-30
Care-PR-31
Care-PR-36

Team Leader Role
Social and Leisure Activities
Social Isolation Prevention
Transfer/ Discharge

40
42
43
47

Care-PR-37

Voting

49

Care-PR-38

Prevention of Resident Abuse and Safeguarding of Vulnerable Adults (SOVA)

50

Care-PR-39
Care-PR-40

Child Protection
Permission to take Photographs of Residents

54
55

Care-PR-41

Oxygen Therapy

56

Care-PR-42

Escorts

58

Care-PR-43

Visitors

60

Care-PR-44

Personal Relationships

Care-PR-45

Missing Resident

Care-PR-46

Pandemic Influenza

64

Care-PR-47
Care-PR-48

Accidental Injury/ Medical Emergency
Pressure Area Damage Prevention

66
68

Care-PR-49

Pressure Area Care

71

Care-PR-50

Pain Management

73

Care-PR-51

Wounds: Prevention and Management

75

Care-PR-52

Wheelchairs and Walking Frames

78

Care-PR-53

Personal Hygiene

79

Care-PR-54

Bathing

81

Care-PR-55
Care-PR-56

Oral Care
Hairdressing

84
87

Care-PR-57

Continence Promotion

89

61
63

-

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Mayflower Care Home

Reviewed 30.03.2017

PROCEDURE

PAGE

Care-PR-58

Care of a Catheterised Resident

93

Care-PR-60

Eye Care

95

Care-PR-61
Care-PR-62

Eye drops and Ointments
Ear Drops and Ear Syringing (Irrigation)

97
100

Care-PR-63

Specimen Collection

102

Care-PR-64

Nutritional Assessment and Care

104

Care-PR-65

Hydration (Fluids)

107

Care-PR-67

Care of a Resident with Diabetes

109

Care-PR-69

Anaphylaxis

112

Care-PR-70

Communicating with a Resident with Sensory Impairment

113

Care-PR-71

Communicating with a Resident with Cognitive Impairment

115

Care-PR-72
Care-PR-73

Managing a Resident with Behaviour that Challenges
Mental Health Related Behavioural Difficulties

116
119

Care-PR-74

Mental Capacity/ Adults with Incapacity

120

Care-PR-75

Spiritual Care of a Resident

125

Care-PR-76
Care-PR-77

Dying and Bereavement
Dealing with the Death of a Resident

128
132

Care-PR-78

Death Verification

135

Care-PR-79

Death of a Loved One

136

Care-PR-85

Medication: Ordering, Storage, Administration, Recording & Disposal

137

Care-PR-86
Care-PR-87

Medication: Monitored Dosage System (Blister Pack)
Medication: As Required Medication

140
143

Care-PR-88

Medication: Resident Self Administration

144

Care-PR-89

Medication: Covert Administration

145

Care-PR-90

Medication: Management of Incorrect Medication

146

Care-PR-91

Medication: Missing Drugs

147

Care-PR-92

Medication: Controlled Drugs

148

Care-PR-93

Medication: Supply whilst resident as away from the Care Home

152

Care-PR-94

Medication: Possession / Handover of Medication Keys

153

Care-PR-95

Medication: Homely Remedies

154

Care-PR-96

Drug Alerts / Hazard Notifications

155

FORMS AND RECORDS

ISSUE

Care-FR-O1a

Resident Profile (Nursing)

1- 03/12

Care-FR-O1b

Resident Profile (Residential)

1- 03/12

Care-FR-02a

Admission Assessment (Nursing)

1-03/12

Care-FR-02b

Admission Assessment (Residential)

1- 03/12

Care-FR-03

Social! Leisure Needs Assessment

1- 03/12

Care-FR-04

Night Profile

1- 03/12

Care-FR-05

Record of Personal Belongings

1- 03/12

Care-FR-06

Dependency Rating Score

1- 03/12

Care-FR-07
Care-FR-08
Care-FR-09

Resident General Risk Assessment
Specific Risk Assessment
Waterlow Risk Assessment

1- 03/12
1-03/12
1- 03/12

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Mayflower Care Home

Reviewed 30.03.2017

FORMS AND RECORDS

ISSUE

Care-FR-10

Moving and Handling Assessment

1- 03/12

Care-FR-11

Continence Risk Assessment

1- 03/12

Care-FR-13

Consent for Restraint

1- 03/12

Care-FR-14

Fall Risk Assessment

1- 03/12

Care-FR-15

Malnutrition Universal Screening Tool (MUST) nursing

1- 03/12

Care-FR-15b

Nutritional Screening Tool (Residential)

1- 03/12

Care-FR-16

Initial Wound Assessment

1- 03/12

Care-FR-17

Pressure Area Diagram/ Body Map

1- 03/12

Care-FR-18

Wound Assessment/ Dressing Record

1- 03/12

Care-FR-19a

Monthly Observations/ Assessments (Nursing)

1- 03/12

Care-FR-19b

Monthly Observations/ Assessments (Residential)

1- 03/12

Care-FR-20
Care-FR-21
Care-FR-22

Weight Record
Advance Care Planning Assessment
Mental Capacity Assessment

1- 03/12
1- 03/12
1- 03/12

Care-FR-23

Care Plan Index

1- 03/12

Care-FR-24

Care Plan

1- 03/12

Care-FR-2S

Care Plan Evaluation

1- 03/12

Care-FR-26

Care Review Form

1- 03/12

Care-FR-27

Daily Progress Sheet

1- 03/12

Care-FR-28
Care-FR-29

Relatives Communication Sheet
Multi-disciplinary Team Member- Visit Record

1- 03/12
1- 03/12

Care-FR-30

Multi-disciplinary Team Member- Communication Record

1- 03/12

Care-FR-31

Doctor's Visit Record

1- 03/12

Care-FR-32

Outpatient Appointment Record

1- 03/12

Care-FR-33

G.P. Request Record

1- 03/12

Care-FR-34

Ambulance Request Form

1- 03/12

Care-FR-35

Investigation/ Specimen Record

1- 03/12

Care-FR-36

Bowel Chart

1- 03/12

Care-FR-37
Care-FR-38

Resident Bath/ Shower Record
Pain Monitoring Chart (Non Communicating Resident)

1-03/12
1- 03/12

Care-FR-39

Pain Monitoring Chart (Communicating Resident)

1- 03/12

Care-FR-40

Catheter History Record

1- 03/12

Care-FR-41

Resident/ Representative Agreement Form

1- 03/12

Care-FR-42

Close Observation Record

1- 03/12

Care-FR-43

Blood Sugar Monitoring Form

1- 03/12

Care-FR-44

Fluid Balance Chart

1- 03/12

Care-FR-4S
Care-FR-46

Missing Resident Details
Positional Changes Chart

1- 03/12
1- 03/12

Care-FR-47

Record of 4 Hourly Subcutaneous Fluid Site Check

1- 03/12

Care-FR-48

Subcutaneous Infusion Record

1- 03/12

Care-FR-49

Night Activity Record

1- 03/12

Care-FR-50

Mini Mental Status Examination

1-03/12

Care-FR-51

Record of Resident's Belongings on Death/ Discharge

1-03/12

Care-FR-52

Record of Resident's Belongings Left to Care Home

1- 03/12

5|P ag e

Mayflower Care Home

Reviewed 30.03.2017
FORMS AND RECORDS

ISSUE

Care-FR-53

Transfer of Resident to Accident and Emergency Unit

1- 03/12

Care-FR-54

Transfer/ Discharge of Resident (Non Urgent)

1- 03/12

Care-FR-55a

Care File Audit (Registered Manager)

1- 03/12

Care-FR-55b

Care File Audit Review (Responsible Individual)

1- 03/12

Care-FR-56

Pre-Admission Assessment

1- 03/12

Care-FR-57

Activities Record

1- 03/12

Care-FR-58
Care-FR-59

Accidents/ Falls Observation Record
Influenza Vaccine Consent Form

1- 03/12
1-03/12

Care-FR-60

Behaviour Record

1- 03/12

Care-FR-61
Care-FR-62

Permission to take Photographs Form
Permission to take Photographs Form (Resident unable to Consent)

1- 03/12
1- 03/12

Care-FR-63

Temperature, Pulse, Respiration Chart

1- 03/12

Care-FR-64
Care-FR-65

Consent to a Shared Room
Deprivation of Liberty Form

1-03/12
1- 03/12

Care-FR-66a

Complaints/Concerns Register

1-03/12

Care-FR-66b
Care-FR-67

Complaints/Concerns Form
Variable Dose PRN Medication

1- 03/12
1-03/12

6|P ag e

Mayflower Care Home

Reviewed 30.03.2017

Care-PR-01
1.0

POLICY PERSON CENTRED CARE

1.1

It is The Company's policy that all residents should be cared for in a person centred way. This means
that the resident should be consulted on all aspects of their care and life. Residents should make their
own decisions wherever possible. Where residents are unable to make their own decisions then staff
should consult with all those involved with the resident and care should be planned with these details
in mind.

1.2

The underlying principle of Person-Centred Care is that the person with is respected as a fellow
human being who happens to have some special needs.
We accord an individual the status of a person when we acknowledge:






His/her unique make up as an individual.
His/her place in the human group.
His/her needs.
His/her value simply because he/she is a human being.
His/her rights.

To support this there are four key elements:





Personal worth - we must feel wanted by somebody.
Agency - we can have an effect on the world around us (we can make things happen,
and make choices)
Social Confidence - we can trust the people we are with.
Hope - we must always feel that things can be better.

1.3

Personhood and personal worth are elements of being that everyone would aspire to, regardless of
what disease labels they have attached to them. Plans of care should not focus on the problems
the resident has but on their abilities, strengths and wishes. They should also include plans to fulfill
residents' wishes concerning their social lives and their life goals. A resident's wishes and life goals may
be simple such as a desire to stay in their own room and not socialise or it may be more complicated such as
resolution of an estrangement with a relative.

1.4

Where a Care Home is unable to fulfill a resident's wishes with regard to their care then this should be
discussed with the resident and a compromise agreed if possible. An advocate may be required to
assist a resident and the staff to agree a plan of care. In some situations it may be that a resident will
require an alternative place of care and this should be dealt with sensitively by the staff.
2.0

RESPONSIBILITIES

2.1

Registered Manager is responsible for ensuring that all staff are aware of the importance of
person centered care. The Care Home Manager is responsible for organising training for all staff

2.2

Person in charge is responsible, in the absence of the Care Home Manager, for the operation of
this policy.

2.3

Team Leader is responsible for ensuring that this policy is implemented as necessary.
During their period of duty they should ensure that care for the resident is in such a way that it
supports the resident to make their own decisions and choices. Documentation should also display
evidence of person centered care.

2.4

All staff have a responsibility to familiarise themselves with this policy and, during their period of
duty, to be aware of residents right to make independent decisions about their life and encourage
them to do so.

3.0

PROCEDURE

3.1

On admission residents should be able to express their wishes with regards to the way they live their
life. A detailed history of the resident's life should be obtained where possible so that the staff can

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Mayflower Care Home

Reviewed 30.03.2017
know the person as they were as well as how they are now.

3.2

Care plans should be written in agreement with residents. Residents that are unable to express their
wishes should still be asked their wishes but the input of those who know the resident well should be
used as well to formulate care plans.

3.3

Documentation should reflect the input of the resident or others who know them well. For example
care plans should state the resident's wishes and choices.

3.4

When offering care to a resident on a daily basis staff must allow the resident to express their choice and
not be expected to comply with a routine. Some routines may be necessary such as meal times but
others are not required such as set bath days.

3.5

The staff should ensure that the environment is such that it enhances the resident's life and provide
stimulation. Large print books, artist materials etc can be used to allow the resident to express him or
herself.

3.6

Staff should be given time to communicate with the residents and be aware of how the residents
communicate.

3.7

Reviews of care plans should include the resident unless they do not wish to be involved.
Consideration should be given to residents' wishes and risk assessments must be written which will
enhance the residents' life and liberty.

3.8

There should be supervisory support for the staff and this should be regular. It should allow the
staff time to discuss situations that are of concern to them.

3.9

Where there is a conflict of the resident's wishes and their needs then this should be resolved by
talking to the resident, explaining the reason for the treatment or act of care and then allowing the
resident the choice of accepting or rejecting the act of care or treatment. If staff or others feel the
resident lacks capacity to make the decision then the Mental Capacity Policy Care-PR-74 should be
followed.

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Mayflower Care Home

Reviewed 30.03.2017

Care-PR-02
1.0
POLICY
EQUAL OPPORTUNITIES:
RESIDENTS
1.1

It is the policy of Mayflower Care Home to provide Residents' with a Care Home environment in which their
individual rights and freedom of choice are respected and actively encouraged by every staff member. These
basic principles are reflected throughout all The Company policies and procedures.

1.2

Each individual is unique and will be respected and afforded dignity in his or her uniqueness.

2.0

RESPONSIBILITIES

2.1

Registered Manager is responsible for ensuring that every Resident is given the opportunity to excersise
their rights and choices as far as their personal ability permits and to ensure that staff
encourages Residents to be involved in living ifs in the Care Home to the fullest extent possible.

2.2

Team Leader is responsible, in the absence of the Registered Manager, for the operation of
this procedure.

2.3

All staff have the responsibility to provide care for Residents, and to ensure that Residents have the
opportunity to participate in activities of their preference and choice as well as participating in the
normal activities of the Care Home.

3.0

PROCEDURE

3.1

Resident's independence

3.1.1

As an integral part of caring for the health and well-being of people, the rights of Residents to have
equal opportunities, to attain maximum independence, and to live to the fullest personal potential
is central to the provision of services.

3.2

Resident's Personal Choices

3.2.1

To ensure that Residents are empowered to make informed choices regarding the various activities of
living in the Care Home and in which they personally may wish to be involved. All appropriate
information is communicated in a manner that will be readily understood by the individual Resident.

3.2.2

Staff will ensure that Residents are given the opportunity and are encouraged to exercise their right to
choose to be involved in planning their care, to be involved in the social activities of the Care
Centre and to pursue their own interests where this is appropriate within the environment of the
Care Home

3.3
3.3.1

Responsible Risk Taking
In order to encourage the Resident to maintain autonomy and independence as far as possible, the
Resident is not precluded from undertaking activities because there is a perceived element of risk
involved. Responsible risk taking is considered the right of the Resident and an integral part of normal
living.

3.3.2

Where concerns are raised regarding the level of risk involved in a particular activity, the matter is discussed
and an agreed course of action determined, if appropriate staff involve the Resident and
Relatives in the discussions to ensure a proper balance between taking risks and ensuring the
Resident's safety is maintained. The result of this discussion should be recorded on the specific risk
assessment form Care-FR-08 and evaluated regularly.
3.3.3

All residents should be assessed for fall risk if mobile (Care-FR-14) and appropriate action taken.

3.4

Residents' Social Needs

9|P ag e

Mayflower Care Home

Reviewed 30.03.2017
3.4.1

Residents are given regular opportunity to satisfy their social and cultural needs by meeting with other
Residents, staff and persons external to the Care Home when and where appropriate. With regard to
the existence of physical or mental impairment, staff will ensure that a respectful and
compassionate attitude is shown to Residents who wish to give expression to their sexuality and to
peruse their interest in their particular religion, observance or cult

3.5

Preservation of Dignity

3.5.1

In providing care to the Resident there are procedures that need to be carried out which, of necessity,
are sensitive in nature. Great care is exercised by all staff involved in such procedures to preserve
the dignity of those who are perhaps less able than they once were.

3.6

Maintenance of Privacy

3.6.1

It is the right of each Resident to exercise their preference for privacy. This is acknowledged and encouraged
and appropriate measures are implemented to ensure that the Residents peers and staff members alike
respect the Residents privacy.

3.7

Confidentiality of Information

3.7.1

In the course of providing caring services to Residents confidential and sensitive information regarding
the Resident is made available, staff members ensure that appropriate records are prepared and used
as necessary whilst maintaining confidentiality of information in accordance with current best
practice, It is a condition of employment that each staff member is required and agrees to maintain
Resident confidentiality.

3.8

Provision of Nutrition

3.8.1

Staff will appreciate the need to provide a varied and appetising range of nutritious food that is
well prepared and attractively presented; during the course of the day staff provide various meals
to suit both the Resident's health requirements and personal preferences.

3.9

Community Involvement

3.9.1

Wherever possible, Residents are encouraged to attend and, if practicable, to participate in the
various activities that take place in the local community. The local community organisations in turn
are encouraged to visit Residents with various events, activities and presentations.

3.9.2

Arrangements are made for Residents to exercise their choice in current local and national
political matters where there is the opportunity to register their preferences by voting.


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